Where the Pain Under Your Heel Comes From: Understanding the Causes of Heel Pain and How Physical Therapy Can Help

If you have ever put a foot down beside the bed and felt your heel object, stood on a kitchen floor long enough to want to shift your weight, walked barefoot across tiles and wished you had not, or felt a deep bruise-like ache that was worse by the evening, you have had heel pain. The causes of heel pain are more varied than the one everybody has heard of.

Here is the part that surprises people. Among 250 people who turned up at one clinic with pain under the heel, 53 percent had plantar fasciitis—and 47 percent had something else. The fat pad accounted for 15 percent on its own, and a further 9 percent had both. Meanwhile, of nearly 820,000 Americans diagnosed with plantar fasciitis over five years, only 7.1 percent ever saw a physical therapist.

The good news? Most settle with the right conservative plan, and telling them apart mostly comes down to two things you can notice yourself before anyone examines you.

At Rooted Motion Physical Therapy, we believe naming the problem properly is the first treatment. Let us look at the causes of heel pain under the heel, how each behaves, and what the evidence supports.

Why “Heel Pain” Is Not Really a Diagnosis

Researchers treat plantar heel pain as an umbrella term rather than a condition. Underneath it sit the plantar fascia, the fat pad, bone stress, nerve irritation and occasionally referred pain from the back. It is common—between 3.6 and 7.3 percent of adults, rising to roughly one in ten in middle age and beyond, and two million office visits a year.

One thing to set aside. Pain at the BACK of the heel, where the Achilles fastens on, is a different problem with its own article. This is about pain underneath.

What Are the Common Causes of Heel Pain Under the Heel?

Four account for most of it, each with its own personality.

• Plantar fasciitis. Worst on the first steps after rest, easing as you walk. Tender on one specific spot on the inner heel. About half of cases.

• Heel fat pad syndrome. A deep, bruise-like ache in the middle of the heel. Worse the longer you stand, worse barefoot or on hard floors, sometimes achy at night, often both heels.

• Calcaneal bone stress. Gradual onset after you increased your walking or running, or changed to a harder surface. Tender over a wide area rather than one point.

• Nerve irritation. Burning, tingling or numbness rather than a plain ache, often running from the inner heel toward the arch. Frequently mistaken for plantar fasciitis.

They are not mutually exclusive; more than one can be true at once.

The nerve one is worth a word on numbers, because you will find very different ones. Estimates run from about 2 percent to as high as 20, and the gap is mostly about who was counted—the low figure from everyone walking into a clinic, the high one from specialist caseloads of stubborn heel pain that had already failed treatment. There is no agreed test either. The useful version is not a percentage: if your pain burns or feels numb, or has not settled with good plantar fasciitis treatment, the nerve is worth considering.

A rough map, not a diagnosis. Pain at the back of the heel is a separate problem.

How the Pain Behaves Narrows It Further

In that same group of 250, certain patterns pulled strongly one way. Pain that worsened with prolonged standing, ached at night, or affected both heels made the fat pad substantially more likely. First-step morning pain and tenderness on that one inner spot pulled hard the other way, toward the fascia.

Treat those as strong signals rather than as a test. The models behind them were not adjusted for age, sex or body weight, and came from a single clinic. And first-step pain is a sensitive clue rather than a specific one: pain after rest turns up in other heel problems too, and it has never been validated as a formal test.

The examination has the opposite character, which is why the two go together. The windlass test—extending the big toe to tension the fascia—is close to perfectly specific, so a positive result means something; but its sensitivity is only about 14 to 32 percent, so a negative rules out little. For suspected bone stress there is a squeeze test across the heel bone. None of it decides anything alone.

Two patterns that pull in opposite directions.

Imagine the Padding in an Old Running Shoe

A new shoe has a resilient pad under the heel that spreads the load of every step. After a few hundred miles it packs down, most where you land hardest. The shoe is not broken—it has stopped cushioning, and you feel the ground through it.

Your heel has its own version of that pad: a shock-absorbing cushion of fat in chambers. With age, long hours standing, high loads or certain health conditions it can thin or lose its springiness. Nothing is torn. There is just less between your heel bone and the floor.

The key idea. These problems feel similar because they are in the same place, but they are different tissues doing different things—and a plan built for one of them is not automatically right for another.

One clinic, reviewed retrospectively. The best breakdown available, and it is a single clinic.

What Does the Research Recommend for the Causes of Heel Pain?

For plantar fasciitis the picture is clearest, because a current clinical practice guideline exists. Its strongest grade goes to stretching that targets the plantar fascia together with the calf, to manual therapy, and to night splints for one to three months where first-step morning pain is consistent. Foot and ankle strengthening gets a slightly lower grade. It recommends AGAINST foot orthoses as an isolated treatment, while allowing them alongside other care.

That last point deserves the fuller picture, because orthoses are what most people are offered first. A meta-analysis found moderate-certainty evidence they reduce pain in the short term by about 12 points on a 100-point scale—and that longer-term effects, and effects on disability, remain uncertain. Both halves are the finding. Exercise is the mainstay, though the newest meta-analysis pooled just three trials in 146 people.

For the fat pad the honest answer is starker. A systematic search found only seven original studies on the condition in the entire literature, and not one randomised trial of the cushioned heel cups and arch taping routinely recommended for it. That does not mean they do not help—it means nobody has properly tested them. Where heel cups have been tested for plantar fasciitis they did not fare well, and taping helps first-step pain only briefly and only while it is on.

Its “second commonest” billing also rests on a couple of studies, and broader reviews list the causes without ranking it second at all. The names drift too—fat pad syndrome, heel pad syndrome, fat pad atrophy used interchangeably for what may be inflammation, thinning or a bursa. Some disagreement between studies is really disagreement about words.

There is a reason heel advice online sounds more confident than this. Of the 95 full papers those reviewers screened, 18 were expert-opinion pieces which, in their words, tended to support their statements by citing other commentaries rather than original research.

Does Strengthening Your Foot Help?

Yes, and the reason is more interesting than it looks.

A systematic review of seven studies found people with pain under the heel test weaker in the muscles that push the foot down and curl the toes—inconsistently, and at very low certainty. Whether those muscles are physically smaller is unsettled: some studies say yes, the best-matched imaging study says no. Calf endurance tests the same as anyone else's.

That argument turns out not to matter much. In a 2026 trial, eight weeks of foot exercise clearly increased toe strength while barely shifting muscle size—so strength and function are what is worth training and measuring, and bulk is not.

And strengthening earns its place: the guideline holds it improves pain and function more than stretching alone. One randomized trial compared high-load heel raises against plantar fascia stretching, both on top of shoe inserts. At three months the strength group was clearly better; by twelve months the two were the same. Honest in both directions—good loading gets you comfortable faster, and this largely settles over a year either way.

When Does Imaging Matter?

Mostly it does not—these are diagnosed from history and examination. One pattern is worth knowing about.

If the pain arrived gradually after a genuine jump in loading and the tenderness is spread across the heel bone rather than on one point, bone stress is worth considering. Plain X-rays are usually the first test and frequently look normal even when a stress fracture is present, which is how these get missed. The reassuring part is that heel bone stress fractures are classed as low-risk and generally settle with activity modification, sometimes with a short period off the foot.

If you have been told your bone density is low, or your periods have changed alongside heavy training, mention it—both are worth a doctor's review.

Everyday Tips That Can Help

• Notice the pattern before your appointment. Worst in the first steps, or after an hour standing? One foot or both? That is genuinely useful information.

• Avoid long barefoot stretches on hard floors while it settles, especially if the ache is deep and central.

• Change one thing at a time, or the cause becomes impossible to identify.

• Treat cushioning as symptom relief, not as the treatment.

• If it burns or feels numb rather than aching, say so — it points somewhere different.

The Rooted Motion Difference

Four problems in one small area, told apart mostly by history and examination, is exactly where an unhurried assessment earns its keep. Fewer than one in thirteen people diagnosed with the commonest of them ever gets a physical therapy evaluation.

Working with us, you can expect:

• A one-on-one evaluation aimed at which tissue is involved.

• Testing of the foot and calf muscles the research suggests are worth measuring.

• A plan matched to the structure, not to the most common label.

• Honest discussion of where the evidence is strong and where it runs out.

• Footwear and loading advice built around your actual week.

• A clear account of what should change, and by when.

• Convenient concierge mobile physical therapy delivered where you are.

Because recovery is not just about healing a heel—it is about helping you get back to living your life.

Ready to Take the First Step Comfortably?

Whether this started on a long day standing, in the middle of a walking routine you were proud of, or with no explanation at all, you do not have to navigate recovery alone. Heel pain is unusually easy to live with badly for a long time—and an assessment that names the tissue involved, followed by a plan built for it, is what changes the trajectory.

Ready to move better and live rooted? Contact Rooted Motion Physical Therapy to schedule a one-on-one evaluation and begin a personalized heel pain recovery plan.

Research Used for This Article

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11. Rathleff MS, Molgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine & Science in Sports. 2015;25(3):e292-300. DOI

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Educational disclaimer: This article is for general education and is not a substitute for an individualized evaluation. Seek medical review if the pain came on gradually after a jump in loading and the tenderness is spread across the heel bone rather than on one point; if the pain burns or feels numb rather than aching; or if you have been told your bone density is low, or your periods have changed alongside heavy training.